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Case Study For Dull Pain In Both Knees Assignment

Case Study For Dull Pain In Both Knees Assignment

Dull pain in both knees with an occasional clicking sound. HPI: The patient is a 15-year-old Caucasian male with complaint of dull knee pain in both knees with an occasional clicking in one or both knees. Patient states “there is a catching sensation under the patella”. Patient reports dull pain with occasional clicking started 2 weeks ago while participating in baseball practice at school. Patient reports dull pain without clicking to both knees during clinic visit. Patient rates pain 4/10. Patient states pain is brought on upon exertion such as baseball practice. Patient denies any other associated symptoms Case Study For Dull Pain In Both Knees Assignment.

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Patient reports taking ibuprofen and applying OTC icy hot patch with little relief. Location: Knees bilaterally. Onset: 2 weeks ago. Character: Dull bilaterally with occasional clicking paired with a catching sensation under patella. Associated signs and symptoms: Patient denies. Timing: Upon exertion in baseball practice. Exacerbating/ relieving factors: Baseball practice, Ibuprofen with little relief. Severity: 4/10 pain scale. Current Medications: Ibuprofen 200 mg 2 tabs po every 8 hours as needed, for 2 weeks for dull pain after practice. OTC Icy Hot patch applied after practice for 1 week used x 3 days as needed after practice. Allergies: PCN (rash). Denies food allergies. Seasonal allergies to pollen (watery eyes, sneezing). Environmental allergies to dust and cats (watery eyes, sneezing). PMHx: Childhood immunizations are up to date. Tdap 08/02/2019. Flu vaccine 10/20/2021. Hx Tonsillectomy on 07/10/2015. Hx Chicken Pox 2013. Soc Hx: NC is a high school freshman and plays on the jr. varsity baseball team. NC lives at home with both parents in a house with his grandmother as the designated caretaker to drops him off and picks him up from school and baseball practice while his parents are working. NC denies tobacco use including nontobacco vaping. NC states he loves “playing GTA” on his PS4 with his friends to relax on weekends. NC reports that he always wears his seatbelt when riding in a vehicle with his parents, grandmother and or friends. NC reports he has a nice family and a good friend group that he can talk to if needed. Fam Hx: Mother 45 yrs old – HTN, overweight. Father 48 yrs old- hx cigarette smoking, nonsmoker currently. Sister 19 yrs old- asthma controlled. Maternal Grandmother 65 yrs old HTN, HLP. Maternal Grandfather deceased at 70 yrs old from CVA, Paternal Grandfather 68- COPD, HTN. Paternal Grandmother 69 yrs old- DM2, HLP. ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. GENERAL: No weight loss, fever, chills, weakness, or fatigue. HEENT Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears: Denies hearing loss or tinnitus. Nose: Denies congestion, sneezing, or loss of smell Case Study For Dull Pain In Both Knees Assignment.
Throat: Denies sore throat. Denies issues swallowing. SKIN: Denies rash or itching. CARDIO/PERIPHERALVASCULAR: Denies chest pain, chest pressure or chest discomfort. Denies palpitations or edema. RESPIRATORY: Denies shortness of breath, cough, or sputum. GASTROINTESTINAL: Denies nausea, vomiting or diarrhea. No abdominal NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: C/o dull knee pain bilaterally with clicking on occasion under patella, reports a catching sensation with click. HEMATOLOGIC: Denies anemia, bleeding, or bruising LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: Denies history of depression or anxiety. ENDOCRINOLOGIC: Denies cold sweats, increased thirst. ALLERGIES: PCN (rash), Dust (watery eyes, sneezing), Cats (watery eyes, sneezing). O. Physical exam General: Pt A&O x4. Sitting upright on exam table with grandmother at side. Pt has a pleasant affect and eager to participate in health interview and exam. Pt is well groomed and dressed appropriate for season.
Pt is ambulatory without assistance. Pt smiles often when speaking about hobbies. Pt has clear speech and goal oriented. VS: BP 110/60, P 74, R 18, T 37.6 C, 02 100% RA, HT 5’7, WT 136, BMI 21.3 RESPIRATORY: Breath sounds clear bilaterally up and lower lobes. No respiratory distress noted. 02 sats 100% RA. CARDIO/PERIPHERALVASCULAR: S1 and S2 noted without rub. Gallops present. Regular rate and rhythm. No murmur detected. No edema present to extremities. MUSKULOSKELETAL: Swelling noted to Left knee. No swelling to R knee. Pt states pain 4/10 bilaterally. Patellar reflexes intact. Knees misaligned. Able to bear weight. Gait steady without need of assistance. L knee flexion 5/5 with pain. R knee flexion 5/5 with pain. Diagnostics: Bilateral Knee X-Ray: To view the orthopedic alignment and degree of arthropathy. X-ray view is used to assess the joint space loss and osteoarthritis or bone fracture (radiopadia.org, 2021). CT Scan: Computed Tomography scan (CT scan) is used to assess knee ligament injury. The CT scan is noninvasive imaging combining both X-Ray and compute technology into slices or cross-sectional images for a sophisticated detailed view of the soft tissue (2022). MRI: Magnetic Resonance Imaging (MRI) is used in producing detailed images of the structures within the knee and the joint. MRI is typically used in diagnosing knee pain, swelling or bleeding around the joint and can help to determine if surgery is required for treatment (radiologyinfo.org, 2022). CBC: Complete Blood Count (CBC) is a serum lab that is used in screening for red blood cells, white blood cells and platelets in which can determine infection and inflammation (questdiagnostics.com, 2018)Case Study For Dull Pain In Both Knees Assignment. A. Primary Diagnosis: Medial Meniscus Tear- Meniscus tears are common in sports that present with pain upon injury, and repeated activity and can break off and leave frayed edges. Tears can develop slowly as the meniscus loses resiliency in repeated injuries (cedars-sinai.org, 2021).

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Differential Diagnoses: Osteoarthritis- The most common form of osteoarthritis is in the knee. Osteoarthritis presents with cartilage in the knee deteriorating and can be exacerbated by repeated strenuous activities (orthoinfo.org, 2021). Patellar Dislocation- Common among children, patellar dislocation occurs when the patellar slips out of place due to injury such as fall. Dislocation can be partial or full and presents with pain and swelling (orthoinfo.org, 2021). Ewing’s Sarcoma- A malignant tumor that begins with bone growth. Usually affects children and young adults and symptoms present in teen years. Typically, the femur is affected (orthoinfo.org, 2021)Case Study For Dull Pain In Both Knees Assignment.

Discussion Response

Hello, I think chondromalacia patellae, or runner’s knee, is the primary diagnosis of the patient’s condition because its description is consistent with the patient’s symptoms. For example, the patient feels dull pain rated four on a scale of 1 to 10 with occasional crackling sound in one or both knees, and the pain intensifies when playing baseball. Health professionals may diagnose the condition as runner’s knee, considering the swelling observed in the left knee during physical examination.

Health professionals would likely rule out medial meniscus tear because its description is not entirely consistent with the patient’s symptoms and observations from the physical examination. For example, while pain and swelling may be characteristic of meniscus tears, the patient can walk steadily without assistance, yet meniscus tears cause limping (Johns Hopkins Medicine, 2022)Case Study For Dull Pain In Both Knees Assignment. Further, the patient explains that he first experienced the pain two weeks ago during sports and was able to tolerate the pain during this period while engaging in additional sporty activities, which is uncharacteristic of meniscus tear experiences. Finally, the patient feels pain in both knees, yet it is unlikely that tears would occur in both knees as the condition develops upon sudden twisting when landing on the ground.

I agree that health professionals will likely rule out osteoarthritis, patellar dislocation, and Ewing’s sarcoma because their diagnostic criteria are not entirely consistent with the patient’s symptoms and physical examination outcomes. For example, osteoarthritis pain worsens progressively with activity and inactivity and may not get better with rest (Hsu & Siwiec, 2022) Moreover, the damage to the surrounding tissue impairs normal gait. Similarly, patients with patellar dislocation cannot walk or engage in sports after the injury (Hayat et al., 2022). Finally, although Ewing’s sarcoma occurs commonly among teenagers, health professionals will likely rule it out because the patient presents with pain in both knees, denies weight loss, and does not report tingling, fatigue, or fever (Johns Hopkins Medicine, 2022)Case Study For Dull Pain In Both Knees Assignment. Indeed, health professionals will likely perform imaging tests to confirm the diagnosis.

References

Habusta SF, Coffey R, Ponnarasu S, et al. Chondromalacia Patella. [Updated 2022 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459195/

Hayat Z, El Bitar Y, Case JL. Patella Dislocation. [Updated 2022 May 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538288/

Hsu H, Siwiec RM. Knee Osteoarthritis. [Updated 2022 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507884/

Johns Hopkins Medicine. (2022). Ewing Sarcoma in Adults. Johns Hopkins Medicine https://www.hopkinsmedicine.org/health/conditions-and-diseases/sarcoma/ewing-sarcoma-in-adults

Johns Hopkins Medicine. (2022). Torn Meniscus. Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/torn-meniscus Case Study For Dull Pain In Both Knees Assignment

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male)Case Study For Dull Pain In Both Knees Assignment. You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance)Case Study For Dull Pain In Both Knees Assignment.

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe Case Study For Dull Pain In Both Knees Assignment.

Example of Complete ROS:

GENERAL:  Denies weight loss, fever, chills, weakness or fatigue.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

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O.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Case Study For Dull Pain In Both Knees Assignment

A.

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting Case Study For Dull Pain In Both Knees Assignment